Romney Has Conciliatory Remarks on Obama and Health Overhaul

3:09 p.m. | Updated Mitt Romney said Sunday that he would retain elements of President Obama’s health care overhaul, blamed Republicans as much as Democrats for the “mistake” of agreeing to automatic cuts in military spending to avoid a fiscal crisis and acknowledged that Mr. Obama’s national security strategy has made America in “some ways safer.”

The remarks, made in an interview on the NBC News program “Meet The Press,” seemed to mark the emergence of a less openly partisan, more general-election-oriented Republican nominee, who is intent on appealing to middle-of-the-road voters who have not yet made up their minds. At one point, Mr. Romney said that a speech on Thursday by the country’s last Democratic president, Bill Clinton, had “elevated” the party’s convention in Charlotte, N.C.

When the show’s host, David Gregory, asked Mr. Romney what elements of Mr. Obama’s health care program he would maintain, Mr. Romney said he would still require that insurance companies cover those with pre-existing conditions, just as the president’s law has.

“I’m not getting rid of all of health care reform,” Mr. Romney said, while emphasizing that he planned to replace the president’s plan with his own. “There are a number of things that I like in health care reform that I’m going to put in place. One is to make sure that those with pre-existing conditions can get coverage.”

Mr. Romney, whose standing in several national polls improved slightly after the Republican convention in Tampa, said, “I’m in a better spot than I was before the convention.”

“People got to see Ann and hear our story,” Mr. Romney said, referring to this wife. “And the result of that is I’m better known, for better or for worse.”

With the Federal Reserve contemplating actions to stimulate the economy, Mr. Romney registered his disapproval, saying that he did not think that “easing monetary policy is going to make a significant difference in the job market right now.”

Mr. Romney, who has criticized the president over the rising federal debt, said he would seek to balance the budget in 8 to 10 years, perhaps after his own potential presidency would end. Any attempt to do so in a first term, Mr. Romney said, would have “a dramatic impact on the economy — too dramatic.”

Mr. Romney said he disagreed with a compromise made last year by the White House and Congressional Republicans that called for automatic cuts to military spending as a way to force a deal on deficit reduction.

“I thought it was a mistake on the part of the White House to propose it. I think it was a mistake for Republicans to go along with it,” he said.

The interview provided another forum in which Mr. Romney was questioned about the omission in his convention speech of any mention of the war in Afghanistan. Mr. Romney seemed defensive when Mr. Gregory asked him about criticism from the conservative magazine The Weekly Standard — and from others on both sides of the ideological divide — ­ that he did not speak about the conflict in accepting his party’s nomination at the Republican convention in Tampa, Fla.

“The Weekly Standard took you to task in your convention speech for not mentioning the war in Afghanistan one time,” Mr. Gregory asked. “Was that a mistake, with so much sacrifice in two wars over the period of this last decade?”

Mr. Romney answered, “You know, I find it interesting that people are curious about mentioning words in a speech as opposed to policy,” noting that he had discussed the war in Afghanistan just before the convention, in a speech to the American Legion. “I went to the American Legion,” he said, “and spoke with our veterans there and described my policy as it relates to Afghanistan and other foreign policy and our military.”

When Mr. Gregory noted that his American Legion address did not have the same large audience as the convention speech ­ — “tens of millions of people” — Mr. Romney replied: “You know, what I’ve found is that wherever I go, I am speaking to tens of millions of people. Everything I say is picked up by you and by others, and that’s the way it ought to be.”

In leaving the war out of his convention address, Mr. Romney seemed to have left an opening for President Obama, who said in his own speech: “Tonight, we pay tribute to the Americans who still serve in harm’s way. We are forever in debt to a generation whose sacrifice has made this country safer and more respected. We will never forget you.”

Pressed on his social views, Mr. Romney reiterated that he did not think that taxpayers should have to pay for abortions and that he wanted Supreme Court to overturn Roe v. Wade.

Reminded that he had once called himself a “severe” conservative, Mr. Romney seemed to play down that description. “I am as conservative as the Constitution,” he said.

In an appearance in Melborune, Fla., Sunday, President Obama, picking up where former President Bill Clinton left off, said that the budget proposals offered by Mitt Romney and Paul D. Ryan do not add up.

The president was quick to jump on appearances by his Republican rivals on the Sunday morning talk shows, in which they were asked separately what loopholes they would close to pay for their proposed tax cuts. Neither of the men answered the question.

The relationship between Mr. Obama and Mr. Clinton started off rocky — Mr. Obama, after all, ran against Hillary Clinton for the Democratic nomination in 2008. But after Mr. Clinton’s ringing endorsement of Mr. Obama in a well-received Democratic convention speech on Thursday, the president mentioned his Democratic predecessor at every stop on a bus tour of Florida over the weekend.

“President Clinton told us the single thing missing from my opponents’ proposal was arithmetic,” Mr. Obama told a rally here, to a burst of applause.

“When my opponents were asked about it today,” Mr. Obama said, “it was like 2 plus 1 equals 5.”

Because of an editing error, an earlier version of this post misstated a subject Mitt Romney addressed during his convention speech. He did not mention conflict in Afghanistan.

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Mixed Message as Republicans Claim Health Law Cuts Medicare

Yet since the Supreme Court upheld the Democrats’ 2010 health care law, Republicans, led by Mitt Romney, have reversed tactics and attacked the president and Democrats in Congress by saying that Medicare will be cut too much as part of that law. Republicans plan to hold another vote to repeal the law in the House next week, though any such measure would die in the Democratic-controlled Senate.

“Obamacare cuts Medicare — cuts Medicare — by approximately $500 billion,” Mr. Romney has told audiences.

That is a reprise of Republicans’ mantra of the 2010 midterm elections, which gave them big gains at both the state and federal levels and a majority in the House. Yet the message conflicts not only with their past complaint that Democrats opposed reining in Medicare spending, but also with the fact that House Republicans have voted twice since 2010 for the same 10-year, $500 billion savings in supporting Mr. Ryan’s annual budgets.

The result is a messaging mess, even by the standards of each party’s usual election-year attacks that the other is being insufficiently supportive of older people’s benefits.

And in this year’s contests, which both parties describe as a referendum on who can best correct the nation’s economic course, such talk underscores how far Republicans and Democrats are from truly squaring with the public about curbing the growth of the major entitlement programs: Medicare, Medicaid and, to a lesser extent, Social Security. That growth is driving the projections of a federal debt that is mounting unsustainably as the population ages and health care costs rise.

“A pox on both their houses,” said Ron Haskins, a former Congressional staff member who is now a scholar of social programs and budgeting at the Brookings Institution. Democrats and Republicans “know they have to do something about Medicare, and then they harass each other about cutting Medicare. It’s so discouraging to me, but I’m a Republican, so I’m much more distraught about Republicans.”

And, Mr. Haskins added, “$500 billion is modest compared to what Ryan would do.”

Under Mr. Ryan’s budget, which Mr. Romney has supported but which has been blocked each year in the Senate, Medicare would not pay for the medical fees of future beneficiaries, as it currently does. Instead it would provide “premium support,” limited payments — vouchers, Democrats say — that beneficiaries could use to buy insurance policies in the private sector. And Medicaid, which increasingly goes toward nursing home care for older people, would become a capped block grant to states, forcing them to make significant cuts.

In their attacks, Republicans have said in speeches and in television advertisements that the Democrats’ projected $500 billion in Medicare savings will “strip,” “gut,” “rob” or “raid” older people’s benefits.

“Ron Barber will hurt Arizona seniors,” said an ad this spring from the House Republicans’ campaign committee in support of the Republican who ultimately lost to Mr. Barber, a Democrat, in a special election to replace Representative Gabrielle Giffords.

Objecting to such attacks, Representative Chris Van Hollen of Maryland, the senior Democrat on the House Budget Committee, said in an interview: “There are two issues here: One, there were no cuts to Medicare benefits. And in fact, benefits were strengthened.”

Independent fact-checking groups have repeatedly knocked down the Republicans’ claims. “A discredited claim is making a comeback following the U.S. Supreme Court ruling upholding most of the national health care reform law,” PolitiFact recently wrote in one such analysis.

Republicans stand by their attack. They say the problem with the Democratic approach is that the reductions do little to bolster Medicare’s stability, with the money diverted to initiatives in the health care law.

“Democrats are still the only party in Washington to cut $500 billion from Medicare in order to help pay for Obamacare,” said Paul Lindsay, spokesman for the National Republican Congressional Committee. “It’s a fact that did not go unnoticed among seniors in 2010, and one that we will continue holding Democrats accountable for in our ads this fall.”

But the $500 billion in reductions would come through cuts in the projected growth of Medicare and would mainly affect hospitals and other providers of medical care, some of whom supported the health care measure nonetheless because it would extend coverage to up to 30 million uninsured Americans, raising the number of paying customers. Other savings would result from lower subsidies for private insurers selling Medicare Advantage plans, which offer older people extra features like vision care and gym memberships. The insurers could not cut basic Medicare benefits.

Democrats used the projected $500 billion in savings to help pay for expanding older people’s benefits. The health care law says that some preventive care services like mammograms must be free to patients, and it closed the “doughnut hole” in the Medicare prescription drug program, which had left many older people paying full price for prescriptions above a certain level.

While Republicans have backed the spending reductions, even as they have attacked Mr. Obama and the Democrats for enacting them, they would end the new benefits.

Mr. Ryan, of Wisconsin, was unavailable for comment, but, pressed on the issue on ABC’s “This Week” on Sunday, he said: “Well, our budget keeps that money for Medicare to extend its solvency. What Obamacare does is it takes that money from Medicare to spend on Obamacare.”

Robert Greenstein, the executive director of the left-leaning Center on Budget and Policy Priorities, called Mr. Ryan’s claim “somewhere between a misstatement and a flat-out untruth.”

Mr. Greenstein, among others, said that Democrats were not double-counting the $500 billion in savings — by claiming that it both improves Medicare’s financial outlook and helps finance new benefits — any more than were the Republicans, who say they would use the savings both to shore up the Medicare trust funds and to reduce the federal debt.

The Congressional Budget Office and the chief actuary for the Medicare and Medicaid programs, Richard S. Foster, have concluded that the $500 billion in savings would extend the solvency of Medicare’s hospital insurance trust fund. Since the passage of the health care law, known as the Affordable Care Act, the Medicare trustees have shifted the projected date of insolvency to 2024 from 2016.

Mr. Foster, in this year’s report by the trustees, wrote that “the Affordable Care Act makes important changes to the Medicare program and substantially improves its financial outlook.”

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Bending Toward Universal Health Care

IN finding the Affordable Care Act constitutional, a narrow majority on the Supreme Court, led by Chief Justice John G. Roberts Jr., has surprised almost everyone. The decision is a victory for the century-long struggle to ensure basic health coverage for virtually all Americans, and it sets the nation on a path toward more rational, cost-effective ways of delivering care. These will be the eventual outcomes — but months and years of fierce political battles lie ahead.

Although the court upheld the act, President Obama’s signature achievement to date, there were important twists. The federal government cannot order all Americans to have or buy health insurance, though it can collect a tax from those who do not have coverage after 2014. The federal government can offer the 50 states money to expand Medicaid coverage to all of the poor and near-poor — but cannot punish states that refuse by fully withdrawing existing Medicaid funds.

The decision shifts the political terrain for both parties. Over the past four years, the Republican Party has given up its traditional commitment to use regulated markets to extend health insurance coverage to all. It was Democrats who passed a law with elements long favored by Republicans — a law that radicalized Tea Party Republicans have now sworn to obliterate.

The ruling does not make President Obama’s tough re-election bid any easier. The health care law, as enacted in 2010, required everyone to buy insurance once it was affordable, but its authors avoided talking about Congress’s power to tax. Now the Roberts opinion makes it impossible to avoid speaking about a tax penalty. Media and legal analysts will want to keep the debates over the individual mandate going, and economists will ask whether taxes will need to be raised to compel recalcitrant holdouts to buy coverage after 2014. Will Mr. Obama be trapped in an endless mandate-discussion loop and forced to expend even more political capital on the one really unpopular part of health reform?

Not necessarily. Mr. Obama can now claim the mantle of “constitutionality” for his health care law — and start talking about the parts that are popular with 60 to 80 percent of Americans. Democrats, indeed all supporters of health reform, can tag Republicans with wanting to repeal or block those popular features like the insurance rules that protect people from being denied coverage for pre-existing conditions; the new benefits for young adults and older people on Medicare; the promised extension of affordable coverage to more than 30 million more low-income and lower-middle-income families; and tax credits for small businesses.

For as long as political scientists have measured public opinion, we have known that Americans respond to abstract questions by opposing “big government” but evaluate particular government benefits and actions very differently. As long as opponents of health reform could ask “Is it constitutional?” the argument was on their terrain. Now the debate will swerve back toward the popular core of the act, if the White House and Congressional Democrats are savvy in how they talk about existing and future benefits. (Reform supporters can also truthfully point out that only 2 out of every 100 people will be affected by the mandate without enjoying subsidies to help them buy affordable coverage.)

Mitt Romney and his fellow Republican refuseniks are in a new bind. They cannot wield the club of nonconstitutionality anymore. And in the debates, how is Mr. Romney going to bash Mr. Obama for extending to all Americans the very same insurance regulations and affordable health coverage that Mr. Romney enacted as governor for the people of Massachusetts — who like the results very much? We predict that Mr. Obama will eat Mr. Romney’s lunch.

Of course, it’s possible that the European economic crisis will send the world economy into another recession; that Mr. Romney and the Republicans will sweep the presidency and both houses of Congress; and that the Republicans will gut financing for the act. Using simple-majority budget rules, they could slash Medicaid and trim or delay subsidies to help low-income families buy private insurance. But they would still not have the 60 votes they’d need in the Senate to actually repeal the act — and the Supreme Court has now left intact the new rules for insurance companies and state-level exchanges prominently included in the law.

Moreover, the Republicans would create a political mess for themselves if they tried to “defund Obamacare,” as many conservative lawmakers have vowed. Insurers would still have to issue policies to all comers, sick or healthy — but they would not get millions of new paid customers using credits and subsidies to buy their products. The states, including those with Republican governors, would be left with millions of citizens needing health care, but much reduced funding to help them. Many insurance companies and health care providers, not to mention health care reformers and Democrats, would fight to restore financing.

The same kind of dynamics would play out for states that choose to opt out of the Medicaid expansion in the act. (The Supreme Court ruled on Thursday that states may do so without losing all of their federal Medicaid financing.) The law provides for 90 percent federal subsidies for expanded Medicaid coverage, and states will find it hard to turn down this offer. As more and more states move toward universal coverage and well-functioning insurance exchanges, states that opt out will have trouble attracting businesses and health care professionals and lose out to other states in economic development.

In short, the historic court ruling ensures the law’s survival in the long run, even if partisan battles over particular regulations and expenditures continue for some time. The arc of history now bends toward health care for all — and greater efficiency in the system as a whole. Mr. Obama and the Democrats may have to talk about health care more than they had planned going into November. But in the months and years ahead, the political challenges for Mr. Romney and the Republicans are even greater.

Theda Skocpol, professor of government and sociology at Harvard, and Lawrence R. Jacobs, professor of political studies at the University of Minnesota, are the authors of “Health Care Reform and American Politics: What Everyone Needs to Know.”

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Too Quiet, Again, on Health Care

Nearly two dozen Pennsylvania residents, interviewed recently by Abby Goodnough of The Times, said they were opposed to President Obama’s health care reform law. Though almost all of them would benefit from it, they expressed fears about a loss of control over their health care that is nowhere in the law.

For Op-Ed, follow @nytopinion and to hear from the editorial page editor, Andrew Rosenthal, follow @andyrNYT.

There are two reasons for this situation, which is repeated around the country. Business groups allied with Republicans have spent $235 million on television ads attacking the law with false accusations, with the vigorous aid of Mitt Romney and his campaign. Meanwhile, Democrats and the Obama campaign have been amazingly reluctant to speak up for the president’s biggest accomplishment and tell voters what’s in it.

The president has not even capitalized on his victory in the Supreme Court last week over his opponents’ attempt to dismantle the law on constitutional grounds. He listed some of its benefits in a low-key East Room speech after the ruling, and the campaign has sent out several direct-mail fliers on the subject to women. But the campaign has broadcast no television ads about health care, except for one in Spanish. Jack Lew, the White House chief of staff, said on “Fox News Sunday” that it was time “for the divisive debate on health care to stop,” suggesting Democrats want to move on.

Mr. Lew might consider going to a swing state and turning on the television because the debate isn’t going to stop. Republicans are happy to continue it with obvious propaganda like “Obamacare is the largest tax increase in U.S. history.” Countering this attack and, more important, building a foundation of support for a vastly important social change, will require the president and other Democrats to spend more time and more money explaining the law’s benefits, and pointing out that Republicans have no useful ideas to replace it.

The White House has been halfhearted in its sales pitch almost from the beginning of Mr. Obama’s administration. Polls showed that many middle-class voters, comfortable with their own insurance, weren’t particularly interested in a new social program that extended coverage to 30 million uninsured people, many of them poor.

Beyond simple decency, that’s a huge benefit to society as a whole, improving public health and reducing expensive emergency care that everyone pays for. In uncertain times, as well, anyone can suddenly lose health insurance. But that case was never forcefully made, and Republicans exploited the complexity of the law to persuade casual listeners that, as the House speaker, John Boehner, claimed on Sunday, “this is government taking over the entire health insurance industry.”

Expanding coverage is an idea worth defending, particularly when Republican leaders acknowledge that they have little interest in doing so, as Senator Mitch McConnell, the Republican leader, did on Sunday. And there many other aspects of the law for which Democrats should use a megaphone: an end to the Medicare “doughnut hole”; a huge expansion of coverage for mental health; an end to lifetime and annual limits on coverage and of rejection because of a pre-existing condition; a requirement that medium and large businesses provide essential coverage and pay for 60 percent of it; free access to preventive care like immunizations and mammograms.

The campaign committee for House Democrats, with little money, is making telephone calls going after Republicans for their votes to repeal the law and loosen the reins on insurance companies. It’s past time for the White House and the Obama campaign to set aside their diffidence and begin playing an equally aggressive offense.

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Will Time Heal Health Care Wounds?

When the Supreme Court declared the Affordable Care Act’s provision for an individual mandate to buy medical insurance constitutional, the majority did so by placing the mandate within Congress’s power to tax rather than under the Commerce clause. While the decision keeps most of the law intact, what does it mean politically? And how will the characterization of the mandate as a tax play among supporters and opponents of the legislation?

Supreme Court rulings on politically prominent issues can have three effects on subsequent attitudes among the public: legitimation, backlash or polarization. As Nathan Persily, Jack Citrin and Patrick Egan show in their 2008 book, “Public Opinion and Constitutional Controversy,” legitimation occurs when public opinion moves in line with the court, as it has over time with regard to the 1954 Brown v. Board of Education school integration decision and to gender equality decisions like Stanton v. Stanton in 1975, which invalidated laws predicated on traditional gender roles that differentiated between men and women in the allocation of government benefits.

Backlash occurs when public opinion moves directly in opposition to the court’s ruling, as when the public shifted, more in favor of school prayer and against flag burning after controversial decisions on those issues. Crucially, under polarization, overall opinion does not shift but different groups move in opposite directions. Examples include the gap in abortion opinion that grew between Protestants and Catholics after Roe v. Wade in 1973 and the difference between liberals and conservatives that widened after the Lawrence v. Texas gay rights decision in 2003.

A look at public opinion during the first few years after the Massachusetts health care reform in 2006 offers some insights into what might happen now at the national level. Although there has not been a legal challenge as dramatic as the suits against the Affordable Care Act, the Commonwealth’s experience does show how public opinion changes with health reform implementation. Of course, the Massachusetts case is different because it is a state-level reform that cannot elicit the objections to federal intervention that the Affordable Care Act. does, and yet the case is informative because the underlying structure of the reform is nearly identical. So what happened? There is evidence of both mild legitimation and pronounced polarization.

Polls by the Harvard School of Public Health in the first years after the law was implemented show that both the health reform overall and the individual mandate became more popular. Support for the Commonwealth’s reform increased from 61 percent in September 2006, shortly after implementation began, to 69 percent two years later, in June 2008. Similarly, support for the individual mandate increased from 52 to 58 percent. Overall support for the reform has dropped and risen since, with the percentage in favor of the mandate falling back to 51 percent. It is not always steady progress.

There is also evidence of sharp partisan polarization over the issue: Democrats became more supportive of the reform and the mandate while Republicans became more opposed, despite the fact that the legislation was signed by a Republican governor (after having passed the Democrat-controlled state legislature). In 2006, Democrats were 12 points more likely than Republicans to support the law (68 to 56 percent). By 2008, that gap had grown to 32 points (76-44).  Similarly, Democrats were 5 points more likely than Republicans to support the individual mandate in 2006 (56 to 51 percent), a gap that grew to 17 points two years later (65 to 48 percent).

Politically we might expect similar polarization at the national level. While increased familiarity and experience with the new legislation may enhance overall support in ways that might elate proponents of the law, implementation also seems to breed antagonism, perhaps precisely because opponents find such success threatening. That the court’s ruling defines the mandate’s penalty as a tax opens up opportunities for damning rhetoric from the reform’s opponents as well. Already we are hearing reminders that candidate Obama promised not to raise taxes on the middle class. As Sarah Palin wrote on Facebook after the court released its decision, “Obama promised the American people this wasn’t a tax and that he’d never raise taxes on anyone making less than $250,000.” Now, she said, we “see that this is the largest tax increase in history.” Glenn Beck’s Web site agreed: “No taxes on the middle class? Lies! Obamacare now Obamatax.”

However, a large group – both in Massachusetts and nationwide – are political Independents, whose opinions are informative because they are one group not constrained by partisanship. Their support for the Massachusetts reform and mandate grew over time, from 60 to 70 percent for the overall reform, from 53 to 58 percent for the individual mandate. With Democrats and Independents constituting a majority of voters nationwide, supporters of the Affordable Care Act may not just celebrate the law’s survival but also have good reason to expect that its popularity will increase — if the law, having made it through the Supreme Court, now also survives the political threat of a Republican repeal effort.

Andrea Louise Campbell is an associate professor of political science at the Massachusetts Institute of Technology. Her April 4 Op-Ed essay, “Down the Insurance Rabbit Hole,” was cited by Justice Ruth Bader Ginsburg in her concurring opinion in the health care decision on Thursday.

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For Opponents of Health Care Law, No Easy Road to Repeal

The court’s ruling that Congress can use its taxing power to assess a penalty fee on Americans who ignore the individual insurance mandate certainly opens a gateway for anti-tax Republicans to attack the law. Should they win the White House and gain even a narrow majority in the Senate, Republicans would be able to use the same procedural approach Democrats took to get the health care law over the finish line two years ago to undo the taxes and federal subsidies that are at the core of the law.

But attacking the law by stripping away its layers of taxes, fees and subsidies is not the same as dismantling it. Undoing the major benefits and policies of the law — which include medical coverage for children up to age 26, protections for people with pre-existing conditions and the end of annual and lifetime caps on certain forms of coverage — would require the acquiescence of Senate Democrats, which is highly unlikely.

In essence, the Republicans could not muster sufficient votes by themselves to undo most of the regulations and benefits of the law, but could for the parts that pay for them.

“You can’t get everywhere with reconciliation,” said Senator Rob Portman, Republican of Ohio, referring to the Congressional process that Democrats used, which allows certain budget measures to pass with 51 votes instead of the 60 that would be required to block a filibuster vote on a full repeal. “You will need to use other procedures,” he said. He added later: “We may get a majority. But we will need to work with the other side.”

While some Republicans fantasize about a bipartisan solution to undoing the elements of the law, Representative Tom Price of Georgia, a physician who is the Republican leadership’s point man on health care, said Friday that a health and human services secretary under a Romney administration would dismantle other parts of the law through fiat.

That would no doubt attract lawsuits and might leave haters of the law unsatisfied.

For their part, Democrats have largely dismissed the biggest blow dealt to the law by the Supreme Court, which said the federal government could not require states to expand their Medicaid programs. Supporters of the law argue that the federal government offers too rich a cash incentive for any state to actually pass it up.

But while Democrats remain publicly confident that states will still choose to take the federal matching funds and expand Medicaid, Republican governors who have made undoing the law one of their main goals will be hard pressed to take up that optional expansion, especially since the federal dollars meant to help them would decrease over time.

Either way, whether Republicans lawmakers pull apart some of the law on their own, or if a large number of states opt out of expanding Medicaid, it will spell trouble for the health care industry. It is counting on the expansion of the market through the individual mandate, fees and the newly insured to cover the cost of greater benefits and regulations.

“It’s problematic to only take down the pieces with budgetary impact and leave the market reforms,” said Catherine Finley, a health care specialist at Thorn Run Partners, a Washington lobbying and government relations firm. “Doing so would seriously disrupt the functioning of the market.”

Both Republicans and Democrats agree in theory that part of the law should be changed, and President Obama has suggested he is open to improvements.

But bipartisanship around health care seems unlikely, no matter who runs Washington.

The central difficulty is the seemingly irreconcilable differences between the goal of most Democrats, which is to expand health care coverage to as many Americans as possible, and that of Republicans, which is to push down government spending on health care. With costs rising sharply every year, those basic conflicts will remain, and policy solutions inevitably will require a bias toward one of those goals.

Further, the partisan bitterness that began long before the Affordable Care Act was even a notion has only deepened during two years of divided government.

For example, in 2009 Republicans who supported the expansion of the Children’s Health Insurance Program felt betrayed when Democrats, taking their lead from the new Obama administration, unilaterally dropped several important features that Republicans had managed to win in an earlier bill at some political risk. Democrats opted for a more partisan bill that covered various groups that Republicans had resisted.

“I’m a little bitter,” said Senator Orrin G. Hatch of Utah. “I worked my butt off” on the measure, he said, only to end up voting against it. “It set the tone.”

Democrats feel equally angry that, in spite of packing the health care bill with many ideas, including the individual mandate, that originated with Republicans years ago, they could get no Republican cooperation in the end.

Many Republicans also say that they would like to preserve many aspects of the law, including the provisions for dependent coverage for adult children and for lifting annual and lifetime spending caps.

However, “it might be difficult for the Romney administration to come back and say, ‘Oh we really like some parts of A.C.A., we are not going to repeal them,’ ” said James Brasfield, a professor of management and political science at Webster University in St. Louis.

It is possible that governors and legislatures may do some of the Congressional Republicans’s work for them by opting out of the Medicaid expansion. But that expansion was going to put 16 million to 21 million additional people into the system.

Insurance companies had or were developing plans to cover these new Medicaid enrollees, also anticipating millions of new customers who were going to buy insurance through new federally subsidized purchasing exchanges. That would be endangered if Republicans legislate away the subsidies, and possibly harm the party’s friendly relationship with the companies.

“That population presents great opportunities for health plans,” Ms. Finley said. “Now we have to see how the states play this out. If they opt out of the expansion, it certainly would decrease the availability of new markets.”

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Seven Consequences of the Health Care Ruling

“I have had some bitter disappointments as president,” Harry S. Truman wrote in his memoirs, “but the one that has troubled me most, in a personal way, has been the failure to defeat the organized opposition to a national compulsory health insurance program.” He was just the first in a long line of presidents stymied by health reform. Now Barack Obama has succeeded where his predecessors failed. Or has he?

The Supreme Court’s blockbuster decision on Thursday has consequences that will reverberate for years. Here are seven big ones.

Passing health reform has always been hard, but now it’s gotten a lot harder. The United States does not have national health insurance for a not-so-simple reason: Congress. The people elect presidential candidates who promise the reform. Congress, through the years, has said, no thanks. It is so difficult because it takes 60 votes in the Senate and tight discipline in the House. By climbing so visibly into the fray, the court served notice that it would become an active part of the process. Yes, the Democrats won — this time. But the decision was close, technical and studded with new barriers to Congressional action on profound challenges that remain. More than 15 million Americans are still uninsured, even with the health reform; the cost of drugs, devices and procedures continues to spiral; worsening inequality has exacerbated enormous differences in health outcomes. Future health reforms will take 60 votes in the Senate and 5 on the bench.

The biggest winner is the Roberts court. The court was drifting into perilous territory. A polite fiction long justified the idea of nine unelected justices overruling Congress and the states: They merely interpret the law. That fiction had been slipping badly ever since Bush v. Gore in 2000. A recent New York Times survey found that three-quarters of the public believed that politics was a frequent factor in court decisions. Political scientists have lots of studies showing just that. Striking down the signal achievement of this administration on a straight party-line vote would have put the court deeper into dangerous territory, with liberals gradually signing up for the longstanding conservative effort to curb the Supreme Court’s powers — perhaps by limiting terms to 15 years, for example. With his exquisitely complicated ruling — siding with the liberals on taxing powers, not on the interstate commerce clause — the chief justice restored the idea that the court is wrestling with the complicated tangle of law — not punching in a partisan vote. In the process, he slipped the health care issue right back to where it belongs: before the voters.

The biggest losers are Medicaid and the poor. Very quietly, the Affordable Care Act introduced a revolutionary change: All poor people in America would get Medicaid. The new law would have extended Medicaid to everyone with incomes up to 133 percent of the federal poverty line ($23,050 a year for a family of four). Aren’t the poor already covered? That depends on where they live. In New York, most adults up to 150 percent of the poverty line are covered; in Texas, Medicaid reaches only to 26 percent of the poverty line — a family of four is not eligible if they earn, say, $9,000 a year. The court ruled that Congress may not require states to expand Medicaid. States can stick to their old Medicaid programs. Stingy states may choose to stay stingy. That part of the decision flew under the media radar. But it is a significant blow to liberals who had a simple way to grow benefits by expanding programs.

For the Obama administration, the hard job begins now. When Truman put national health insurance in play, he did something bizarre. He refused to argue for it. While opponents cried “socialism,” Truman remained mum. That silence became a not so proud Democratic legacy. As soon as Mr. Obama proposed the legislation, opponents began repeating “death panels,” “taxes” and “government takeover”; the Democrats responded by getting down into the policy weeds of their complicated law. The president’s statement on Thursday was a case in point. Down the checklist he went: policy details, moving story, pivot to the economy. When you say health reform, my summer neighbors in New Hampshire all nod their heads and say “death panels.” The question for Obama and the Democrats: What do you have that will match that? If they don’t come up with something stirring, the reform that survived the court could be lost in the election.

Big changes are ahead for health care. When the Clinton health reform went down to defeat in 1994, something curious happened. The health care system ran with many of the reforms that the Clintons had recommended. The managed-care revolution sprang from the failed reform. The Obama reform promises even greater changes: new incentives for hospitals to deliver more efficient care, new incentives to nudge physicians into primary care, and powerful new rules to stop insurance companies from cherry-picking the people they cover. The court gave the hospitals, doctors and insurance companies a green light to run with these changes. In many cases, they will. The medical system is going to change regardless of what Mitt Romney might do in his first week in office.

For the Republicans, “no” is not enough. Republicans have their campaign slogan: Repeal and replace! But history has a funny lesson for them. Every Republican administration in the past 60 years has proposed health care reform. There is no escaping it. What is the next Republican administration’s health care policy going to look like? There are plenty of popular provisions in the Affordable Care Act. The party of “hell, no” might be wise to think of ways to remake the law in its own image. Repeal may sound good now, but history is unambiguous. An administration without a health policy will soon be vulnerable to attacks. Cruel! Unfeeling! Out of touch! A quiet Republican conversation about what to cut, what to keep, and what to change will pay big dividends in the future.

But Democrats can’t rest easy. The Supreme Court weakened a major prop of classical liberalism: the interstate commerce clause. When Congress passed the blockbuster Civil Rights Act of 1964, it relied on its interstate commerce powers. Even an Alabama barbecue shack with a local clientele could not discriminate against blacks; after all, it served food that came from out of state. The Supreme Court this week backed way off from that expansive reading of the commerce clause. Mainstream Democrats looking to expand social welfare policies have gotten lazy: they’ve recycled Republican ideas — Bill Clinton borrowed from Richard M. Nixon the idea of building on employer-based private insurance to achieve national coverage, and Barack Obama borrowed from Republicans like Senator John Chafee of Rhode Island the idea of mandating individual coverage to broaden the private insurance pool. It’s high time for the Democrats to get more creative.

An earlier version of this article misstated the location of a barbecue
shack that was barred, by the Supreme Court, from discriminating against black customers following the passage of the Civil Rights Act of 1964. It was in Alabama, not Atlanta.

James A. Morone, a professor of political science at Brown, is the co-author of “The Heart of Power: Health and Politics in the Oval Office.”

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In Health Ruling, Relief for Obama but a Blow to Conventional Wisdom

The Supreme Court’s 5-to-4 decision on Thursday to uphold most of President Obama’s health care law represents a hurdle cleared for Mr. Obama. He had been at risk of seeing his most ambitious policy initiative — and most expensive, in terms of the political capital it required — neutered or
overturned by the court.

If Mr. Obama is the victor from the standpoint of public policy, however, some observers have claimed that the decision could help Mitt Romney in terms of electoral politics.

With due respect, I think this counterintuitive conclusion is too cute by half. It may involve the same sort of wishful thinking that liberals were guilty of when some began to argue that the court striking the health care bill would actually help Mr. Obama politically.

Other analyses issued before the decision had implausibly argued that both Mr. Romney and Mr. Obama could benefit from the law being upheld. They seem to forget that in contrast to public policy, electoral politics is largely a zero-sum game.

The health care law is likely to remain fairly unpopular; opinions about it have been essentially unchanged for most of the last two years. The bill was probably partially responsible for the significant losses that Democrats endured in the 2010 midterm elections.

But continued dissatisfaction over the health care bill was presumably already priced into the polls. A decision that upholds the status quo is not likely to change that much.

To the extent there are marginal effects of the court’s decision, they would seem to be positive for Mr. Obama. The framework of the bill has now been endorsed by the court, including by John G. Roberts Jr., the relatively conservative and relatively well-respected Chief Justice who wrote the majority opinion.

To be clear, the risks to Mr. Obama may have been somewhat asymmetric. A decision to strike the law might have harmed him more than the decision to uphold it will help.

And be wary of whatever the polls say for the next week or two — the short-term reaction to the news of the ruling may not match its long-term political effects. As before, the presidential election is mostly likely to be contested mainly on economic grounds. Next week’s jobs report is likely to have a larger effect on the election than what the Supreme Court ruled on Thursday.

But particularly given the public’s confusion over the health care law, my view has been to keep it simple: Mr. Obama got the good headline here, and that is likely to be most of what the public reacts to.

It is not as though, if the law had been struck down, Republicans would have stopped talking about the folly of the legislation. Members of the public, in mostly opposing the law, had not been objecting to its technical details, some of which they actually supported when quizzed about the specific aspects of the health care overhaul.

Instead, it was to the impression that it represented an overreach on behalf of Mr. Obama — at a time when there is profound skepticism about the direction of government and the efficacy of its policy — that left him vulnerable.

When the dust settles, it seems implausible that Mr. Obama would have been better off politically had his signature reform been nullified by the court. Then Mr. Obama’s perceived overreach would have had the stench of being unconstitutional.

Some of the analyses that claim the law could help Mr. Romney instead argue that Thursday’s decision could motivate the Republican base. But the Republican base was already reasonably well motivated for the election. A decision to strike down the law, meanwhile, would have represented a victory for movement conservatism — and victory can be its own motivating force.

Although some liberals had claimed that a decision to strike the law could have motivated Democratic turnout in anger against the Supreme Court’s decision, it can likewise be argued that it would have left Democrats despondent, particularly given that any efforts to replace an overturned law would have faced huge political obstacles in the near term. The effects on the party bases are hard to sort out.

It is what passes for conventional wisdom that may have been the clearest loser with the court’s decision. Sentiment in prediction markets and among pundits had been that the law was more likely than not to be overturned.

As I wrote on Wednesday, some of these analysis may have gotten ahead of themselves in trying to read the tea leaves.

Statistical methods to predict the court’s decision, which have been more reliable than expert judgment in the past, had pointed to a case that was too close to call.

In another blow to conventional wisdom, the decision to uphold the law came in a 5-to-4 vote, but with Chief Justice Roberts voting with the four liberals on the court while Justice Anthony M. Kennedy voted with the conservatives — and he signed a strongly worded dissenting opinion that claimed the entire law should have been struck down.

This permutation had been considered unlikely by experts, most of whom had predicted a 6-to-3 ruling for the law, or a 5-to-4 ruling against it, with Justice Roberts and Justice Kennedy voting together in either case. And if the decision had been 5 to 4 in favor of the law, it was thought that Justice Kennedy and not Chief Justice Roberts would have been more likely to join the majority.

Who came out looking better than the pundits? Interestingly, it may be high school students.

High school students participating in a Supreme Court “fantasy league” sponsored by the nonprofit Harlan Institute had been about evenly divided in predicting the court’s decision, with 57 percent thinking the mandate would be overturned and 43 percent saying it would be upheld.

Nor did the oral arguments in the case, which substantially affected the conventional wisdom, alter the students’ opinions much. Instead, they had seen the case as a tossup from the beginning.

I suspect these students would have been wise enough to avoid some of the counterintuitive speculation about the decision’s political effects that you will now be seeing on television.

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Massachusetts Health Law Is Celebrated, With a Poke at Romney

Erik Jacobs for The New York TimesGov. Deval Patrick, center right, with Jack Connors, the head of Partners HealthCare System, on Wednesday in Boston during an event highlighting Massachusetts’ health care overhaul.

BOSTON — Former Gov. Mitt Romney, needless to say, did not attend. But at a sixth-anniversary celebration of Massachusetts’ landmark health care law on Wednesday, Gov. Deval Patrick, a Democrat, pointedly said his predecessor should be proud of the law, which has been a hot potato for Mr. Romney on the Republican presidential campaign trail.

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On April 12, 2006, Mitt Romney, then the governor of Massachusetts, signed a health care bill into law, with Senator Edward M. Kennedy, center, and Tim Murphy, the state health secretary.

“I know, or at least I sense, that he’s personally proud of it,” Mr. Patrick said, pointing out that Mr. Romney’s official portrait in the State House depicts him sitting at a desk with a document stamped with a medical symbol, meant to represent the health care legislation.

Mr. Patrick, a co-chairman of President Obama’s re-election campaign and a vocal proponent of Mr. Obama’s national health care overhaul, stressed that Mr. Romney had embraced the piece of the Massachusetts law, known as the individual mandate, requiring most residents to get health insurance. The Supreme Court is weighing whether a similar component of Mr. Obama’s law is constitutional, and if not, whether the entire law must be overturned.

On Thursday — the actual anniversary of Mr. Romney’s signing of the Massachusetts law — the state’s Democratic Party will hold a “birthday party” for it, complete with a cake and punch.

“It’s hard to believe that it was only six years ago that then-Governor Romney shared the president’s position that we should take on rising health care costs and provide affordable, accessible health care to all Americans,” John Walsh, chairman of the Massachusetts Democratic Party, said in a statement.

Mr. Romney opposes Mr. Obama’s health care law, saying the federal government should not prescribe such a sweeping measure for all states. But Mr. Romney has defended the law he signed here as appropriate for Massachusetts.

Andrea Saul, a spokeswoman for Mr. Romney, described the anniversary celebrations as “business as usual from Deval Patrick and the Beacon Hill machine.”

Mr. Patrick — speaking at Faneuil Hall here, where Mr. Romney signed the health care bill into law on April 12, 2006 — said he wanted to combat inevitable criticism leading up to the presidential election by highlighting the law’s success.

“Everybody around here who has participated in creating and sustaining the success of this program,” Mr. Patrick said, “whether we support or not the incumbent president, is not going to stand by and let it be intentionally misrepresented.”

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Jonathan Gruber, Health Care’s Mr. Mandate

They all wanted Jonathan Gruber, a numbers wizard at M.I.T., to help them figure out how to fix their health care systems, just as he had helped Mitt Romney overhaul health insurance when he was the Massachusetts governor.

Then came the call in 2008 from President-elect Obama’s transition team, the one that officially turned this stay-at-home economics professor into Mr. Mandate.

Mr. Gruber has spent decades modeling the intricacies of the health care ecosystem, which involves making predictions about how new laws will play out based on past experience and economic theory. It is his research that convinced the Obama administration that health care reform could not work without requiring everyone to buy insurance.

And it is his work that explains why President Obama has so much riding on the three days of United States Supreme Court hearings, which ended Wednesday, about the constitutionality of the mandate. Questioning by the court’s conservative justices has suggested deep skepticism about the mandate, setting off waves of worry among its backers — Mr. Gruber included.

“As soon as I started reading the dispatches my stomach started churning,” Mr. Gruber said of the arguments on Tuesday, while taking a break from quizzing his son for a biology test. “Losing the mandate means continuing with our unfair individual insurance markets in a world where employer-based insurance is rapidly disappearing.”

Mr. Gruber, 46, hates traveling without his wife and three children, so he is tracking the case from his home in Lexington, Mass. There he crunches numbers and advises other states on health care, in between headbanging at Van Halen concerts with his 15-year-old son and cuddling with the family’s eight parrots. (His wife, Andrea, volunteers at a bird rescue center.)

If the court rules against the mandate, Mr. Gruber says he believes the number of newly insured Americans could fall to eight million from the projected 32 million. He insists that without a mandate, the law will result in a terrible spiral: only relatively sick Americans will choose to get insurance, leading premium prices to rise and causing the healthier of even those sick people to drop their insurance, sending prices higher and higher.

Some other economists quibble, though, with Mr. Gruber’s pessimistic assessment.

“My general thought about the mandate is if insurance is affordable and accessible, most people will buy it anyway,” said David Cutler, an economist at Harvard and longtime collaborator of Mr. Gruber’s.

Others, like Paul Starr, a Princeton sociologist, say they believe Mr. Gruber’s work does not account for how hard it will be to enforce the mandate.

“There is this groupthink about how important the mandate is,” Mr. Starr says. “Most people don’t understand or won’t acknowledge how weak the enforcement mechanism is.”

Mr. Starr said he thought Mr. Gruber in particular was overstating the effectiveness of the mandate because “it’s his baby.”

 That said, it is difficult for too many other experts to categorically refute Mr. Gruber’s work, since he has nearly cornered the market on the technical science behind these sorts of predictions. Other models exist — built by nonprofits like the RAND Corporation or private consultancies like the Lewin Group — but they all use Mr. Gruber’s work as a benchmark, according to Jean Abraham, a health economist at the University of Minnesota and former senior economist in both the Obama and George W. Bush administrations.

“He’s brought a level of science to an issue that would otherwise be just opinion,” Mr. Cutler says. “He’s really the only person who has been doing all this careful modeling for so long. He’s the only person you can go to for that kind of thing, which is why the White House reached out to him in the first place.”

Mr. Obama had made health care reform a cornerstone of his campaign, and wanted to announce a credible proposal quickly after taking office. But members of the Obama administration’s transition team said they had inherited an executive branch that had vastly underinvested in modeling research on health care, especially compared to the technical modeling that had been done in areas like tax policy.

“Creating a good model from scratch would have taken months, maybe years,” said Lawrence H. Summers, who was the director of President Obama’s National Economic Council and had advised Mr. Gruber on his dissertation when they were at Harvard.

Mr. Gruber had already spent years researching government mandates, starting with his 1991 dissertation about how mandated employer benefits cut into workers’ wages.

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Whatever the Ruling in Health Case, Bipartisan Fallout

The political side of the president may need to draw upon his judicial patience as he awaits a ruling that will help shape the final stages of the presidential race.

For all of the fretting by liberals and the tea-leaf reading by legal analysts about the pointed questioning from the justices about the health law, there is but one certainty: There will be substantial political fallout no matter how the court rules.

Successful political races, particularly presidential campaigns, are built on planning for every likely outcome. Mitt Romney, should he secure the Republican nomination, would confront tricky political calculations regardless of the ruling, given his role in enacting a health care law in Massachusetts built around the same type of mandate at the heart of the Supreme Court case.

But for the White House and the president’s re-election team, the challenge begins immediately. They must publicly defend the law’s constitutionality and push back against suggestions that the battle is already lost, even as they privately piece together a contingency plan if the law — or part of it — is overturned.

The early outlines of the plan came into view on Wednesday as the administration aggressively promoted the more popular provisions of the health care law. That offered a glimpse of the next three months, as the court wrestles with its ruling on the most sweeping piece of domestic legislation since Medicare was created in 1965.

“It’s foolhardy to try to predict the outcome of this decision based solely on the questions of the judges,” said Josh Earnest, a White House spokesman. He added, “If there is a reason or a need for us to consider some contingencies down the line, then we’ll do it then.”

It was two years ago that Mr. Obama stood in the East Room of the White House and signed the health care bill, pausing as his supporters in the crowd sounded the old rallying cry of his presidential race: “Fired up! Ready to go!” Health care had been an important issue in his campaign, but hardly the central thrust.

If the Supreme Court strikes down the health care law, Republicans hope to make it a prominent element of their effort to deny him a second term.

“It would be a tremendous validation,” Gov. Bob McDonnell of Virginia, a Republican, said in an interview. “A victory in court would say that a trend toward big government solutions out of Washington has a limit and the biggest accomplishment of the Obama administration is unconstitutional.”

If the administration loses its argument, one early strategy is to run squarely against the Supreme Court. Democrats believe that Mr. Obama could fashion himself as a modern-day Franklin D. Roosevelt, trying to convince voters that a majority of the justices are in the pocket of the Republicans. A Democratic senator on Wednesday referred to that as the “martyr strategy.”

That approach, while galvanizing for Democrats, could also unify conservatives who have been slow to embrace Mr. Romney, in part because of his record on health care.

If he becomes the nominee, Mr. Romney would confront an uncertain dynamic with any of the potential outcomes from the Supreme Court. He told Wisconsin voters on Wednesday that he was closely following the legal arguments.

“If they find it unconstitutional and strike down the legislation, why, they would have done us all a great service,” Mr. Romney said, speaking on a conference call from Texas, where he was attending fund-raisers. “If for some reason it survives the Supreme Court or if it’s only struck down in certain provisions and not very broadly, we’ll have to deal with Obamacare in the other branches of the government.”

For the last year, Mr. Romney has spoken out against the Obama administration’s health care overhaul and has pledged to repeal it. But Mr. Romney continues to face skepticism among conservatives over the Massachusetts law that he championed, which, like its federal counterpart, is built around a requirement that everyone purchase health insurance.

But both sides, even as they quietly make contingency plans in their respective campaign headquarters, in Chicago and Boston, acknowledge that they must wait until the court rules, most likely at the end of June, to grasp fully the way forward.

Despite suggestions from some Democratic activists that a ruling against the administration could energize the party and place the burden of finding a national health care solution on the Republicans, a loss at the Supreme Court would undoubtedly be significant for Mr. Obama. A decision to strike down the mandate or the entire bill would give greater legitimacy to the broader conservative argument that Mr. Obama has been expanding the size and reach of the federal government beyond what the Constitution allows.

One Democratic adviser compared it to “a bad bloody nose” that would bleed for days or weeks. The television advertising, particularly in an era of unlimited donations to “super PACs” lining up against Mr. Obama, would be “a disaster,” another Democratic aide said, with an endless loop of headlines about the president’s signature accomplishment being rejected.

Yet several other Democrats, even as they maintained their belief that the law would be found constitutional, said the Supreme Court could become a central issue in the fall campaign.

“If this court overturns the individual mandate, it will galvanize Democrats to use the courts as a campaign issue,” said Neera Tanden, president of the Center for American Progress, a liberal research organization. “The idea that we would have gone through Bush v. Gore, Citizens United and now this.”

Mr. Obama, who has signaled his intention to run against Congress in the mold of Harry S. Truman, could add the Supreme Court to his list of antagonists. It remains an open question whether the argument will resonate as it did in 1936 for Roosevelt.

Michael D. Shear contributed reporting.

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If Health Law Is Overturned, What Will Liberals Do?

If the Supreme Court strikes down all or part of President Obama’s health care law, it will have unraveled a legislative compromise that many liberals had viewed with suspicion from the beginning.

In one of the ironies of recent politics, Mr. Obama was a late convert to the merits of the individual mandate that now appears to be in danger of being declared unconstitutional.

But the president’s embrace of the mandate — and his willingness to abandon a so-called public option to get a health care deal — was a hard pill to swallow for many of his Democratic supporters.

The Affordable Care Act promises to provide health insurance to millions who lacked it. But it also stops far short of the idea that health care is a basic right for everyone living in the country. And it embraces the market-based system of private health care delivery that has long existed in America.

For many progressive activists and voters, the decision by the court in June could reopen a debate that they thought they had lost two years ago. Rather than be dismayed if the court overturns the health care law, some liberals may see it as an unexpected opportunity.

Politically, there is almost no chance of a new effort to achieve universal health care coverage before the election in the fall. But if the current law is overturned, eventually there would be a new push from Democrats to achieve the goals they have pursued for decades.

Still, it’s far from clear how progressives might regroup if the court rules against the mandate, as Tuesday’s questions from the justices suggested they might.

Here are three possibilities:

SALVAGE: If the justices invalidate the individual mandate but stop short of declaring the entire law unconstitutional, progressives could try to fix it through other means.

Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology, has suggested a couple of options. Mr. Gruber was an adviser to both Mitt Romney on his health care plan in Massachusetts and to Mr. Obama.

In a paper written last year for the Center for American Progress, a research and advocacy group, he said the mandate could be replaced by a requirement that people “auto-enroll” in health insurance but with the ability to opt out if they wanted to.

Or, he said, people could be encouraged to buy insurance, and fined a penalty if they signed up after a deadline. That might encourage more participation in the health insurance market by young, healthy people.

But Mr. Gruber concluded that neither would be particularly effective, saying that “both alternatives significantly erode the gains in public health and insurance affordability made possible by the Affordable Care Act.”

EXPAND: If the court declares large parts of the health care law unconstitutional, another option for liberals would be a return to advocating other methods to expand the number of people covered by insurance.

They could push for an expansion of Medicare to include coverage of people at an earlier age. And they could seek to include more people in government-run health care programs that cover children and the poor.

Neera Tanden, president of the Center for American Progress, said she remained hopeful that the court would uphold the health care law. But if it doesn’t, she said she remained skeptical about other proposals.

“There is no proposal that I am aware of that operates without an individual mandate that gets you to that level of coverage,” she said in an interview with The Caucus on Tuesday.

Congress would be unwilling to act on expansions of government health care programs if the current law is invalidated.

“We are a long way away,” from another successful legislative effort on health care, she said. “It would be decades, and may not be in my lifetime.”

SINGLE PAYER: If Democrats make little progress on alternatives, some purists might decide it’s best to just renew the case for a single-payer system in which all Americans receive health care paid for by the government.

Sidney M. Wolfe, the director of the Health Research Group at Public Citizen, an advocacy group, has been pushing for government-run health care for decades.

In an interview Tuesday, Mr. Wolfe said a ruling against the current law could help start a renewed drive for a system that essentially expanded Medicare into a program for everyone, not just the elderly.

“If this is what happens, it may offer more incentive to say let’s decide once and for all that health care is a right,” Mr. Wolfe said. “It will certainly present an opportunity to a number of people.”

But it’s not clear where the support for such a change would come from, especially after the bruising fight over Mr. Obama’s health care plan two years ago. Ms. Tanden said that she did not believe the country would support such a change.

“I am not holding my breath for the Medicare-for-all option. Most people in America feel comfortable with the health insurance they have,” she said. “I would say to my progressive allies: the reason we have all been supporting the individual mandate is because it is the way in which we can get to near-universal coverage in my lifetime.”

“They may look at this as an opportunity to carry that torch again,” she added. “I don’t think the Congressional response is to look at single-payer as the option.”

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Study shows health care bill may have cost Democrats the House - Washington Post

???initialComments:true! pubdate:03/09/2012 11:15 EST! commentPeriod:14! commentEndDate:3/23/12 12:15 EDT! currentDate:3/8/12 7:0 EST! allowComments:true! displayComments:true!Posted by Aaron Blake at 11:15 AM ET, 03/09/2012

A top Democrat acknowledged Thursday that President Obama’s health care bill hurt his party in 2010. And a new study suggests it cost the Democrats something pretty specific: their House majority.

“It was clearly a liability in the last election in terms of the public’s fear,” House Minority Whip Steny Hoyer (D-Md.) said Thursday during a briefing with reporters.

The study, by five professors from institutions across the country, looks at the health care bill alongside other contentious votes in the 111th Congress and determines that, more so than the stimulus or the cap-and-trade energy bill, it cost Democrats seats. In fact, they lost almost exactly the number of seats that decided the majority.
House Minority Whip Steny Hoyer (D-Md.) after the House vote on the payroll tax cut extension in December. (REUTERS/Yuri Gripas)

The study ran 10,000 simulations of a scenario in which all vulnerable Democrats voted against the health care bill and found that the rejections would have saved Democrats an average of 25 seats, which would have made the House parties close to a tie. (Republicans won 63 seats overall, but the study suggests around 25 of them would have been salvaged.)

In 62 percent of the simulations, Democrats were able to keep the House.

The study uses district-level data to show that the vote created “ideological distance” between the Democratic members of Congress and the median voters in their districts, compared with similar districts where the Democratic incumbent voted against the bill.

“Democratic incumbents who supported health care reform were seen as more liberal on average by their constituents than those who did not,” the study says.

The study comes at an important time for the health care bill — just as it’s threatening to become a major issue again in the 2012 election.

The U.S. Supreme Court is set to take up a challenge to the individual mandate portion of the bill later this month when it holds oral arguments. Republicans are licking their chops, hoping to rekindle the kind of enthusiasm they reaped from attacking the bill two years ago, just as enthusiasm seems to be on the decline in the GOP.

Democrats, meanwhile, are planning to celebrate the two-year anniversary of the bill’s passage later this month as part of an ongoing effort to make sure the bill isn’t a political liability going forward.

Hoyer said that whatever harm the bill might have caused his party electorally two years ago, the effects are more mitigated now.

“I think some of the fears they had have not been realized,” Hoyer said. ”Therefore, I think you’ve dissipated the opposition. Republicans are going to use it, but I don’t think it’s as fertile soil as they had two years ago.”

The health care bill, in many ways, is a kind of sleeping giant. But it’s about to be awakened, and how the parties navigate the issue in the coming weeks and months will go a long way toward determining how the 2012 election pans out.

Associated Press 

Felicia Sonmez 

Rosalind S. Helderman 

Glenn Kessler 

Nia-malika Henderson 

T.w. Farnam 

Chris Cillizza; Aaron Blake 

Rachel Weiner 

::unspecified:: 

Lisa Rein 

Al Kamen 

Jason Horowitz 

Rachel Weiner 

Karen Tumulty 

Glenn Kessler 

Aaron Blake 

Aaron Blake 

Sari Horwitz 

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